67:16:11:19.02. Claim requirements -- Private duty nursing -- Extended home health
aide services. A claim for private duty nursing and extended home health
aide services provided in this chapter must be submitted on a form or in an
electronic format that contains the following information:

Note: The CMS 1500 form
substantially meets the requirements of this rule and its content and
appearance are acceptable to the department. These forms are available for
direct purchase through the Superintendent of Documents, U.S. Government
Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing desk.